This review of 133 arteriovenous (AV) fistulas, created by implantation of polytetrafluoroethylene (PTFE) graft material, reports an infection rate of 16.4% in the first period from 1982 to 1985. The infection rate decreased to 5.6% in the period from 1986 to 1990. Graft infections occurred at a higher rate of 46.2% versus 20% when reoperations because of malfunction, occlusion, aneurysm, or bleeding were necessary.Graft infections can be reduced by the development of standard surgical procedures, by the local and systemic application of antibiotics, and by a careful puncture technique. The treatment of septic graft complications after primary operations resulted in a maintenance of graft function in 50%. After secondary operations the graft had to be excised in all but 1 case.

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Injury and stress are accompanied by a characteristic hormonal response and altered energy utilisation. Hyperglycaemia and negative nitrogen (N) balance are the leading symptoms of the metabolic changes in the post-operative state. In a prospective, randomised study the efficacy and metabolic effects of glucose-xylitol (GX) 35% (1:1) versus glucose (G) 40% were investigated in patients undergoing major surgery. METHOD. Twenty-four patients undergoing abdomino-thoracic oesophageal cancer surgery were treated in a standardised manner. Total parenteral nutrition was administered over 6 days (kg body wt.-1/day): day of surgery 1-1.25 g carbohydrate (CH); 1st postoperative day (POD) 1.5 g CH, 1 g amino acids (AA); 2nd POD 3 g CH, 1.5 g AA, 1.0 g fat; from 3rd POD 3 g CH, 1.5 g AA, 1.5 g fat (CH GX35% (n = 12) or G40% (n = 12), AA Intrafusin 15%, fat Intralipid 20%). Daily and cumulative N balances, blood-G profiles, blood chemistry, and physical parameters were determined. Glucagon and insulin profiles, CH losses, and oxalic acid secretion were measured. RESULTS. Both groups were comparable for age, body mass index, clinical and physical parameters, and blood chemistry. Mean cumulative N balances after 6 days were -12.0 +/- 16.3 g N for GX35% and -5.6 +/- 19.4 g N for G40% (n.s.; Wilcoxon, P < 0.05). Blood G was similar for both groups with values ranging from 130 to 240 mg/dl on the day of surgery and below 150 mg/dl on the consecutive days. In each group 1 patient needed additional insulin therapy. Glucagon and insulin levels did not show a significant difference between the groups. CONCLUSION. No difference in tolerance and efficacy of nutritional support by GX versus G at a dose of 3 g.kg body wt.-1.d in oesophagectomised patients could be observed. Similar blood G profiles were in accordance with comparable glucagon and insulin levels. Because of the high standard deviations of N balances, differences in efficacy could not be proven. A significantly lower level of pseudocholinesterase (PCHE) for G40% on day 7 might indicate enhanced hepatic protein synthesis in the GX group.

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Die hochkalorische vollständige parenterale Ernährung in der postoperativen Phase ist nicht bei jedem Patienten sinnvoll, bei dem sich eine enterale Nahrungszufuhr vorübergehend verbietet. Vor allem die niedrigkalorische, eiweißorientierte, periphervenöse Ernährung kann bei mittelschwerer Katabolie eine gute Alternative darstellen. In einer offenen prospektiven Studie wurden 18 weibliche Patienten nach Dickdarmeingriffen während 4 Tagen mit einer Komplettlösung, bestehend aus Sorbit 80 g, Xylit 40 g, 70 g AA und einem Elektrolyt-zusatz, ernährt. Bei dieser 700 kcal-Diät waren die Stickstoffbilanzen mit einem mittleren täglichen Verlust von 4 g nur leicht negativ. Die Routinelaborparameter änderten sich kaum. Die Homöostase der freien Plasmaaminosäuren konnte aufrecht erhalten werden, so daß die Voraussetzung für eine optimale Verwertung der zugeführten Nährlösung gegeben sein dürfte. Allgemeine Nebenwirkungen konnten nicht festgestellt werden. Die untersuchte eiweißorientierte Komplettlösung nach dem Kartof-fel-Ei-Muster kann für die hypokalorische periphervenöse Ernährung empfohlen werden.